When a virus takes over

The coronavirus pandemic has also hit the German Navy hard. However, thanks to close cooperation with the naval medical service, it was still possible to fulfil orders.

Global crises such as Sars in 2003, the Ebola epidemic in 2014-2016 and the Zika outbreak in 2016 have already shown the need to link measures in the areas of prevention, warning and response more closely. However, by the end of 2019, most countries, including Germany, had failed to do this adequately.

On 30 January 2020, the World Health Organisation (WHO) declared the Covid-19 outbreak an international health emergency. This was followed by the declaration of a pandemic on 11 March. This came as a surprise to the civilian population, government institutions and the naval medical service alike.

The January declaration instructed an infectiological control strategy as part of the implementation of the overarching directive for the fleet. This focussed on reducing the risk of infection and quickly containing outbreaks while ensuring service operations.

One of the first measures was to set up a medical situation and information centre at the naval command. Its task was to manage the situation and coordinate all Covid-related measures in extended daytime and weekend operations to ensure a response capability within three hours.

Further measures were instructed or recommended to contain the infection. These included

- Implementation of hygiene concepts on the units of the fleet and naval service centres ashore
- Arrangement of basic measures to minimise virus transmission
- Temporary limitation of training to pre-deployment matters
- Instructions on how to deal with returnees from holidays and coronavirus hotspots
- Pre-deployment protective measures for crews of seagoing units
- Measures to isolate infected persons and remove them from the ship

The last two points had a direct impact on service operations on board, which are characterised by cramped conditions.

In the absence of a vaccine or a targeted treatment option in the early stages, special protective measures were required to maintain the operational capability of the fleet and to ensure the necessary participation of the units in manoeuvres, deployments and operational commitments. The main objective was to prevent the crews from becoming infected. This was to be achieved by isolating the crews before deployment and restricting external contacts.

On the units, the on-board medical service was responsible for implementing and monitoring the infection protection measures in preparation for and during deployment:

- PCR and antigen testing of the crew for Sars-CoV-2, both regularly and on an ad hoc basis,
- Regular instruction on hygiene measures, antigen self-tests and symptoms of infection with Covid-19,
- daily health checks and
- preparing for the isolation of suspected cases on board.

The pandemic highlighted the conflict between military mission fulfilment and the restrictions imposed by medical infection control measures. The gold standard for infection control was a fortnight of individual isolation for crew members prior to deployments. However, this was no longer applicable in spring 2020 when the BERLIN task force supply ship had already been deployed. In order to minimise the risk of an infection-related loss of crew and at the same time achieve effective infection control, the BERLIN used the fourteen-day cohort isolation as an alternative procedure during transit to the theatre of operations. This consisted of

- Testing of the crew on Sars-CoV-2 before departure,
- Wear a face mask at all times and strictly adhere to the hygiene regulations,
- daily health checks,
- Regular and ad hoc PCR testing,
- Reducing the number of people at mealtimes by organising meals in shifts,
- Refrain from using fitness equipment and
- Final complete testing of the crew immediately before integration into the unit.

This allowed the unit to take part in the mission as planned. During this time, with a Covid-free crew that had tested negative, the risk of bringing the virus on board was significantly reduced by consistently avoiding unnecessary external contact. However, this came at a price. As a result, the crew of the frigate MECKLENBURG-VORPOMMERN were unable to leave the ship for nine weeks.

If contact between the crew and the "outside world" was unavoidable, as in the case of embarked staff, contact with the functional personnel of a harbour or other units, there was a risk of the virus entering the crew. The challenge of isolating infected persons in the cramped conditions on board and the deployment of essential key personnel under protective measures in individual cases despite infection was overcome in the fleet without jeopardising the fulfilment of the mission.

In general, inconsistent national Covid control strategies posed further challenges for the embarkation of personnel on naval units abroad as well as repatriation to Germany. The solution lay in the use of cohort and individual isolations as well as extensive testing to ensure freedom from the virus. For example, international staff embarked on missions were isolated as an independent cohort as completely as possible from the crew and maximum hygiene measures were ordered. In addition, soldiers who tested negative were issued with a written medical certificate before being transferred to the receiving unit.

Situation relaxation?
Nine months after the Covid pandemic was declared, the European Commission granted the pharmaceutical companies Biontech and Pfizer conditional marketing authorisation for their mRNA-based vaccines. The availability of a vaccine was accompanied by a vaccination obligation for all members of the German Armed Forces. On board seagoing units, the organic on-board medical service vaccinated the crew members with the vaccines that were supplied from the Bundeswehr pharmacies to the operational flotillas and other naval services. This eased the situation on board. The strict cohort isolation of the crews in preparation for deployment was gradually relaxed and lifted with the full vaccination programme. The external contact regulations were also adapted, which meant that life on board returned to normality, at least in part. Nevertheless, the established hygiene measures to reduce and control the ongoing virus transmission were maintained.

Even among the fully vaccinated crew members, it quickly became apparent that the available vaccines did not protect against infection, but that the infection was mild or asymptomatic. In September and October 2022, a coronavirus outbreak occurred on board the frigate RHEINLAND-PFALZ immediately before participating in the NATO manoeuvre Heimdall. In the course of the outbreak, 32 people, including key system-relevant personnel, were demonstrably infected. By immediately taking appropriate protective measures, it was possible to contain any further spread during sea operations and ensure participation in the manoeuvre.

Lessons learnt
Although the high proportion of young people on board the seagoing units and the increasing knowledge about Covid-19 suggested a mild course of the disease, the continuation of the hygiene concept and protective measures even after the crews had been fully vaccinated was justified with regard to the employer's duty of care. Repatriated infected persons with symptoms requiring treatment and coronavirus outbreaks on board despite full vaccination of the crew confirm this.

The evidence currently available confirms the effectiveness of the vaccines against fatal courses of Covid-19 infection. It remains to be seen to what extent infections, symptomatic courses and long Covid symptoms also have long-term effects on the health status of younger people despite vaccination. As long as there is no reliable evidence on such an issue, protective measures and hygiene concepts in exceptional infectiological situations must always be subjected to a careful risk-benefit assessment with regard to the fulfilment of the mission as well as the individual operational capability and health resilience of the soldiers.

Throughout the pandemic, it was evident that the measures instructed for the Navy were effective. By weighing up and appropriately prioritising the fulfilment of the mission, the measures made it possible to deal with the pandemic in a controlled manner and interrupt the chains of infection.

However, without the discipline of the crews in implementing these measures - even accepting numerous restrictions on personal development - the fleet's endurance would not have been guaranteed given the large number of obligations and missions. The strain on the soldiers due to isolation, compulsory masks and the ban on shore leave was undoubtedly significantly increased.

Ultimately, the German Navy's management of the pandemic is the result of constructive cooperation between the troops and the naval medical service.

Stephanie Pape, retired flotilla pharmacist, is assigned to the Planning/Concept Department of the Naval Medical Services Division at the Naval Command.

Stephanie Pape